<form action="us-perso.php" method="POST">
<table BORDER=0 CELLSPACING=1  CELLPADDING=1><tr>
<td><input type=TEXT name=block1 size=10 maxlength=10></td>

<td><font color=#150185><b><center>USA<input type=hidden name=land value=usa></td>
<td><input type=TEXT name=block2 size=15 maxlength=15></td>
<td><input type=TEXT name=block3 size=1 maxlength=1></td>
</tr>
<tr><td colspan="6"><INPUT type=submit value=Anfordern&nbsp;!></center></td></tr>
</table></form>